Provider Demographics
NPI:1972341345
Name:VANDIVER, JOSEFINA CYNTHIA
Entity type:Individual
Prefix:
First Name:JOSEFINA
Middle Name:CYNTHIA
Last Name:VANDIVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19501 E 390 RD
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:OK
Mailing Address - Zip Code:74016-3028
Mailing Address - Country:US
Mailing Address - Phone:918-541-4097
Mailing Address - Fax:
Practice Address - Street 1:1395 JUNGERMANN RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7369
Practice Address - Country:US
Practice Address - Phone:636-485-7606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK000000000000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation